Healthcare Provider Details

I. General information

NPI: 1033510045
Provider Name (Legal Business Name): WILLIAM T CAMPBELL LAT, ATC, CEIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 NEUMANN WAY 140
EVENDALE OH
45215
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 513-446-6082
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT. 004086
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: